Adapting an equity-focused implementation process framework with a focus on ethnic health inequities in the Aotearoa New Zealand context.

BACKGROUND: Health intervention implementation in Aotearoa New Zealand (NZ), as in many countries globally, usually varies by ethnicity. Maori (the Indigenous peoples of Aotearoa) and Pacific peoples are less likely to receive interventions than other ethnic groups, despite experiencing persistent health inequities. This study aimed to develop an equity-focused implementation framework, appropriate for the Aotearoa NZ context, to support the planning and delivery of equitable implementation pathways for health interventions, with the intention of achieving equitable outcomes for Maori, as well as people originating from the Pacific Islands. METHODS: A scoping review of the literature to identify existing equity-focused implementation theories, models and frameworks was undertaken. One of these, the Equity-based framework for Implementation Research (EquIR), was selected for adaptation. The adaptation process was undertaken in collaboration with the project's Maori and consumer advisory groups and informed by the expertise of local health equity researchers and stakeholders, as well as the international implementation science literature. RESULTS: The adapted framework's foundation is the principles of Te Tiriti o Waitangi (the written agreement between Maori rangatira (chiefs) and the British Crown), and its focus is whanau (extended family)-centred implementation that meets the health and wellbeing aspirations, priorities and needs of whanau. The implementation pathway comprises four main steps: implementation planning, pathway design, monitoring, and outcomes and evaluation, all with an equity focus. The pathway is underpinned by the core constructs of equitable implementation in Aotearoa NZ: collaborative design, anti-racism, Maori and priority population expertise, cultural safety and values-based. Additionally, the contextual factors impacting implementation, i.e. the social, economic, commercial and political determinants of health, are included. CONCLUSIONS: The framework presented in this study is the first equity-focused process-type implementation framework to be adapted for the Aotearoa NZ context. This framework is intended to support and facilitate equity-focused implementation research and health intervention implementation by mainstream health services.

A scoping review of equity-focused implementation theories, models and frameworks in healthcare and their application in addressing ethnicity-related health inequities.

BACKGROUND: Inequities in implementation contribute to the unequal benefit of health interventions between groups of people with differing levels of advantage in society. Implementation science theories, models and frameworks (TMFs) provide a theoretical basis for understanding the multi-level factors that influence implementation outcomes and are used to guide implementation processes. This study aimed to identify and analyse TMFs that have an equity focus or have been used to implement interventions in populations who experience ethnicity or 'race'-related health inequities. METHODS: A scoping review was conducted to identify the relevant literature published from January 2011 to April 2022 by searching electronic databases (MEDLINE and CINAHL), the Dissemination and Implementation model database, hand-searching key journals and searching the reference lists and citations of studies that met the inclusion criteria. Titles, abstracts and full-text articles were screened independently by at least two researchers. Data were extracted from studies meeting the inclusion criteria, including the study characteristics, TMF description and operationalisation. TMFs were categorised as determinant frameworks, classic theories, implementation theories, process models and evaluation frameworks according to their overarching aim and described with respect to how equity and system-level factors influencing implementation were incorporated. RESULTS: Database searches yielded 610 results, 70 of which were eligible for full-text review, and 18 met the inclusion criteria. A further eight publications were identified from additional sources. In total, 26 papers describing 15 TMFs and their operationalisation were included. Categorisation resulted in four determinant frameworks, one implementation theory, six process models and three evaluation frameworks. One framework included elements of determinant, process and evaluation TMFs and was therefore classified as a 'hybrid' framework. TMFs varied in their equity and systems focus. Twelve TMFs had an equity focus and three were established TMFs applied in an equity context. All TMFs at least partially considered systems-level factors, with five fully considering macro-, meso- and micro-level influences on equity and implementation. CONCLUSIONS: This scoping review identifies and summarises the implementation science TMFs available to support equity-focused implementation. This review may be used as a resource to guide TMF selection and illustrate how TMFs have been utilised in equity-focused implementation activities.

Supporting implementation of interventions to address ethnicity-related health inequities: frameworks, facilitators and barriers - a scoping review protocol.

INTRODUCTION: Health inequities are differences in health between groups of people that are avoidable, unfair and unjust. Achieving equitable health outcomes requires approaches that recognise and account for the differences in levels of advantage between groups. Implementation science, which studies how to translate evidence-based interventions into routine practice, is increasingly recognised as an approach to address health inequities by identifying factors and processes that enable equitable implementation of interventions. This article describes the protocol for a scoping review of the literature relating to the equitable implementation of interventions, focusing on ethnicity-related health inequities. The scoping review aims to identify equity-focused implementation science theories, models and frameworks (TMFs) and to synthesise and analyse the evidence relating to the factors that aid or inhibit equitable implementation of health interventions. METHODS AND ANALYSIS: The scoping review is guided by the methodology developed by Arksey and O'Malley and enhanced by Levac and colleagues. Relevant literature will be identified by searching electronic databases, grey literature, hand-searching key journals and searching the reference lists and citations of studies that meet the inclusion criteria. We will focus on literature published from 2011 to the present. Titles, abstracts and full-text articles will be screened independently by two researchers; any disagreements will be resolved through discussion with another researcher. Extracted data will be summarised and analysed to address the scoping review aims. ETHICS AND DISSEMINATION: The scoping review will map the available literature on equity-focused implementation science TMFs and the facilitators and barriers to equitable implementation of interventions. Ethical approval is not required. Dissemination of the results of the review will include publications in peer-review journals and conference and stakeholder presentations. Findings from the review will support those implementing interventions to ensure that the implementation pathway and processes are equitable, thereby improving health outcomes and reducing existing inequities.

Awareness and use of family planning methods among iTaukei women in Fiji and New Zealand.

OBJECTIVE: iTaukei women's awareness and practice of family planning methods was investigated in New Zealand and Fiji to ascertain differences in behaviour within the context of changing developmental settings. METHODS: The study was cross-sectional in nature and recruited women aged 18 years and over from three suburbs in Suva, Fiji, and five cities in New Zealand. RESULTS: Overall, 352 women participated in the study, 212 in Fiji and 140 in New Zealand. The study found that living in New Zealand was significantly associated with lower odds of being aware of family planning (OR 0.4, 95%CI 0.2-0.9, p=0.029) and using family planning methods (OR 0.5, 95%CI 0.2-0.9, p=0.027). Tertiary education was found to increase the odds of being aware (OR 2.8, 95%CI 1.3-6.2, p=0.009) and of using (OR 3.9, 95%CI 1.9-7.8, p=0.000) family planning. CONCLUSIONS: Despite the greater availability of services and higher standards of living experienced in New Zealand compared with Fiji, there was no improvement in awareness and use of family planning among New Zealand participants. Implications for public health: Reduced awareness and use of family planning in New Zealand indicates a need for better targeting of services among minority Pacific ethnic groups.

Family planning unmet need and access among iTaukei women in New Zealand and Fiji.

AIM: The aim of the study was to identify unmet need and family planning access among indigenous Fijian or iTaukei women living in New Zealand and Fiji. METHOD: A cross-sectional survey was undertaken between 2012-2013 in five major cities in New Zealand: Auckland, Hamilton, Wellington, Christchurch and Dunedin; and in three suburbs in Fiji. Women who did not want any (more) children but were not using any form of contraception were defined as having an unmet need. Access experiences involving cost and health provider interactions were assessed. RESULTS: Unmet need in New Zealand was 26% and similar to the unmet need found in Fiji (25%). Cost and concern over not being seen by a female provider were the most problematic access factors for women. CONCLUSION: There is a need for better monitoring and targeting of family planning services among minority Pacific groups, as the unmet need found in New Zealand was three times the national estimate overall and similar to the rate found in Fiji. Cost remains a problem among women trying to access family planning services. Gendered traditional roles in sexual and reproductive health maybe an area from which more understanding into cultural sensitivities and challenges may be achieved.

Hand sanitisers for reducing illness absences in primary school children in New Zealand: a cluster randomised controlled trial study protocol.

BACKGROUND: New Zealand has relatively high rates of morbidity and mortality from infectious disease compared with other OECD countries, with infectious disease being more prevalent in children compared with others in the population. Consequences of infectious disease in children may have significant economic and social impact beyond the direct effects of the disease on the health of the child; including absence from school, transmission of infectious disease to other pupils, staff, and family members, and time off work for parents/guardians. Reduction of the transmission of infectious disease between children at schools could be an effective way of reducing the community incidence of infectious disease. Alcohol based no-rinse hand sanitisers provide an alternative hand cleaning technology, for which there is some evidence that they may be effective in achieving this. However, very few studies have investigated the effectiveness of hand sanitisers, and importantly, the potential wider economic implications of this intervention have not been established. AIMS: The primary objective of this trial is to establish if the provision of hand sanitisers in primary schools in the South Island of New Zealand, in addition to an education session on hand hygiene, reduces the incidence rate of absence episodes due to illness in children. In addition, the trial will establish the cost-effectiveness and conduct a cost-benefit analysis of the intervention in this setting. METHODS/DESIGN: A cluster randomised controlled trial will be undertaken to establish the effectiveness and cost-effectiveness of hand sanitisers. Sixty-eight primary schools will be recruited from three regions in the South Island of New Zealand. The schools will be randomised, within region, to receive hand sanitisers and an education session on hand hygiene, or an education session on hand hygiene alone. Fifty pupils from each school in years 1 to 6 (generally aged from 5 to 11 years) will be randomly selected for detailed follow-up about their illness absences, providing a total of 3400 pupils. In addition, absence information will be collected on all children from the school rolls. Investigators not involved in the running of the trial, outcome assessors, and the statistician will be blinded to the group allocation until the analysis is completed. TRIAL REGISTRATION: ACTRN12609000478213.

Determinants of inequalities in cervical cancer stage at diagnosis and survival in New Zealand.

OBJECTIVE: The aim of this study is to assess whether ethnic inequalities in cervical cancer mortality are due to differences in survival independent of stage and age at diagnosis, and to assess the contribution of screening to stage at diagnosis. METHODS: Demographic data and cervical screening history were collected for 402 women with histologically proven primary invasive cervical cancer, diagnosed in New Zealand between 1 January 2000 and 30 September 2002. Date of death was available for women who died up to 30 September 2004. RESULTS: A Cox proportional hazard model showed that, after adjusting for age, the Maori mortality rate was 1.80 times (95% CI 1.07-3.04) that of non-Maori. This reduced to 1.25 (95% CI 0.74-2.11) when stage at diagnosis was also adjusted for. Among determinants of late stage at diagnosis, older age and being Maori significantly increased the risk, while screening was protective. CONCLUSIONS: These results indicate that later stage at diagnosis is the main determinant of Maori women's higher mortality from cervical cancer. Improving cervical screening among Maori women would reduce stage at diagnosis and therefore ethnic inequalities in mortality.

Making policy decisions about population screening for breast cancer: the role of citizens' deliberation.

OBJECTIVE: To test a method of assessing whether a community of interest - when well informed - would be prepared to support or reject a public policy decision about cancer screening. In particular, whether the New Zealand government should offer free mammography screening to all women aged 40-49 years. METHODS: Eleven women aged from 40 to 49 years, randomly selected from the electoral roll, agreed to participate in trial of a citizens' jury: a deliberative method of gathering the views of the public. Only selected aspects of the jury method were trialled. Participants met over a day and a half to hear evidence from expert witnesses with differing views and to deliberate the verdict. RESULTS: All but one woman changed their minds during the jury process, and voted against government provision of mammography screening in this age group. The main reasons reported were the inaccuracy of the test and the potential for harm, and the lack of firm evidence of saving lives in this age group. CONCLUSIONS: A deliberative 'citizens' jury' approach is a feasible way of eliciting a well informed, considered community view about screening or other population health initiatives. Pro-screening views of affected populations may change when individuals are given accurate information and enabled to deliberate about benefits and harms. This method could be used to determine how complex benefits and harms are weighed by affected populations, particularly where experts and advocacy groups disagree.

Food and nutrient availability in New Zealand: an analysis of supermarket sales data.

OBJECTIVE: To examine food and nutrient availability in New Zealand using supermarket sales data in conjunction with a brand-specific supermarket food composition database (SFD). DESIGN: The SFD was developed by selecting the top-selling supermarket food products and linking them to food composition data from a variety of sources, before merging with individualised sales data. Supermarket food and nutrient data were then compared with data from national nutrition and household budget/economic surveys. SETTING: A supermarket in Wellington, New Zealand. SUBJECTS: Eight hundred and eighty-two customers (73% female; mean age 38 years) who shopped regularly at the participating supermarket store and for whom electronic sales data were available for the period February 2004-January 2005. RESULTS: Top-selling supermarket food products included full-fat milk, white bread, sugary soft drinks and butter. Key food sources of macronutrients were similar between the supermarket sales database and national nutrition surveys. For example, bread was the major source of energy and contributed 12-13% of energy in all three data sources. Proportional expenditure on fruit, vegetables, meat, poultry, fish, farm products and oils, and cereal products recorded in the Household Economic Survey and supermarket sales data were within 2% of each other. CONCLUSIONS: Electronic supermarket sales data can be used to evaluate a number of important aspects of food and nutrient availability. Many of our findings were broadly comparable with national nutrition and food expenditure survey data, and supermarket sales have the advantage of being an objective, convenient, up-to-date and cost-effective measure of household food purchases.